Dementia with Lewy Bodies comprises an estimated 20% of dementia cases with males and those over the age of 60 being most often diagnosed. While this type of dementia shares many common features with Alzheimer’s and dementia in Parkinson’s disease, it is a unique and quite complex condition.
Objectives
To understand what DLB is.
To understand how DLB differs from similar conditions.
To learn how DLB is diagnosed.
Provide information for examination and assessment of DLB.
Provide evidence for treatment methods to be used with DLB.
Provide resources on DLB
What is Dementia with Lewy Bodies?
Dementia with Lewy Bodies is due to the presence of Lewy Bodies in the brain. They are believed to interfere with transport between neurons resulting in disconnections in the cortex. The Consortium on Dementia with Lewy Bodies identified a set of criteria for a clinical diagnosis of DLB. The central feature is a rapidly progressive cognitive decline that leads to occupational and social dysfunction in conjunction with the following three core features: fluctuating cognition, Parkinsonian motor features (mainly rigidity and bradykinesia), and vivid and recurrent visual hallucinations.
Another prominent clinical feature of DLB is attention and visuospatial defects. Recurring falls is also an issue. According to a study by Imamura et al., falls are significantly more common in DLB than in AD and also did not attribute the falls to Parkinsonian motor symptoms. The reason for recurrent falls has yet to be determined. Individuals with DLB may also demonstrate depression, delusions, auditory hallucinations, REM sleep behavior disorder, and social inappropriateness.
DLB is often misdiagnosed as Alzheimer’s or dementia of Parkinson’s disease (PDD) because of many overlapping symptomology. There are many things that separate DLB from PDD and Alzheimer’s. If the Parkinsonian symptoms are present for at least a year prior to the onset of dementia, then the diagnosis is PDD. Onset of dementia a year prior to or simultaneously with onset of Parkinsonian symptoms constitutes DLB. Patients with DLB are also less responsive to Levadopa. Memory deficits are also different in DLB versus AD. Patients with AD often have more difficulty acquiring and storing memories while those with DLB struggle with retrieving memories. They also show much more visuospatial and visuoperceptual dysfunction and attention deficits.
Examination & Assessment of DLB
The 3 main clinical domains of DLB are cognitive, psychiatric, and motor. Examination and assessment of motor features should include balance and fall risk. Tests that address visuospatial dysfunction should also be included. It is also important to note that one should avoid placing too much reliance on cognitive assessments due to the rapidly fluctuating nature of DLB.
Cognition/Memory – Mini Mental State Exam, Abbreviated Mental Test Score, Memory Impairment Screen, Cambridge Assessment of Memory & Cognition
Visuospatial – Clock Drawing, Pentagon Drawing
Psychiatric/Behavioral – Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, BEHAVE-AD, Cornell Scale for Depression in Dementia, Geriatric Depression Scale
Functional –Informant Questionnaire on Cognitive Decline in the Elderly, Bristol ADL scale, Barthel index, Lawton IADL scale
Quality of Life – DEMQOL, Short-form 36 (more generic)
Caregiver Burden – Zarit Burden Interview, General Health Questionnaire (more generic)
Management of Dementia with Lewy Bodies
There is currently no cure for DLB. Treatments are focused on controlling cognitive and behavioral issues, Parkinsonian motor symptoms, and psychiatric symptoms.
Pharmacological Therapy
The standard pharmacological intervention for DLB is cholinesterase inhibitors to treat the cognitive symptoms. Levadopa is used to address the Parkinsonian motor symptoms. Levadopa is much more effective for Parkinson’s disease treatment, but patients with DLB also show improvements with use of Levadopa. Serotonin reuptake inhibitors are used to treat depression since DLB responds less favorably to tricyclic antidepressants. Clonazepam or melatonin is used to treat REM sleep issues if they are present. Extreme caution must be taken if neuroleptics are to be used to treat hallucinations. Neuroleptics can actually exacerbate DLB symptoms so they are typically avoided.
Nonpharmacological Management
As previously mentioned, individuals with DLB are at increased risk of falls. Therefore, they may benefit from prescription of assistive devices and mobility aids from occupational and physical therapy. Extensive training should be given with these aids and therapists should provide written instructions due to memory impairments. Education on fall prevention should also be given to the patient and caregivers. It may be necessary to make certain home modifications to improve safety of the environment such as removing rugs and clutter. Environmental modifications can also be made in order to help with the psychiatric issues that accompany DLB. For example, removing or covering mirrors may help prevent visual hallucinations or delusions. Also, when a patient is experiencing a hallucination, do not try to dispute or correct them but rather distract them or change locations.
Physical therapy programs can provide lots of additional benefits for patients with DLB. Exercise is a healthy and effective coping mechanism for stress and may help combat the depression that DLB patients often encounter. Physical therapists can also teach patients various relaxation techniques. Balance and fall prevention exercises should also be included.
Tips for Caregivers:
Help the individual maintain a regular daily routine
Avoid environments that are unfamiliar
Use physical contact.
Encourage social interaction and hobbies
Be aware of body language
Make eye contact when communicating
Remember to take care of yourself as well. Seeking out support groups may be beneficial.
Bonder, B., & Dal Bello-Haas, V. (2009). Functional Performance in Older Adults (3rd ed.). Philadelphia: F.A. Davis.
Buracchio, T., Arvanitakis, Z., & Gorbien, M. (2005). Dementia with lewy bodies: Current concepts. Dementia and Geriatric Cognitive Disorders, 20(5), 306-20.
Budson, A. E., & Kowall, N. W. (2011). The handbook of Alzheimer's disease and other dementias. Chichester, West Sussex, UK: Wiley-Blackwell.
Guccione, A., Wong, R., & Avers, D. (2012). Geriatric Physical Therapy (3rd ed.). St. Louis: Elsevier/Mosby.
Hanyu, H., Sato, T., Hirao, K., Kanetaka, H., Sakurai, H., & Iwamoto, T. (2009). Differences in clinical course between dementia with Lewy bodies and Alzheimer’s disease. European Journal of Neurology, 16(2):212-217.
Imamura, T., Hirono, N., Hashimoto, M., Kazui, H., Tanimukai, S., Hanihara, T., Takahara, A., Mori, E. (2000). Fall-related injuries in dementia with Lewy bodies (DLB) and Alzheimer’s disease. European Journal of Neurology, 7(1):77-79.
Objectives
What is Dementia with Lewy Bodies?
Dementia with Lewy Bodies is due to the presence of Lewy Bodies in the brain. They are believed to interfere with transport between neurons resulting in disconnections in the cortex. The Consortium on Dementia with Lewy Bodies identified a set of criteria for a clinical diagnosis of DLB. The central feature is a rapidly progressive cognitive decline that leads to occupational and social dysfunction in conjunction with the following three core features: fluctuating cognition, Parkinsonian motor features (mainly rigidity and bradykinesia), and vivid and recurrent visual hallucinations.
Another prominent clinical feature of DLB is attention and visuospatial defects. Recurring falls is also an issue. According to a study by Imamura et al., falls are significantly more common in DLB than in AD and also did not attribute the falls to Parkinsonian motor symptoms. The reason for recurrent falls has yet to be determined. Individuals with DLB may also demonstrate depression, delusions, auditory hallucinations, REM sleep behavior disorder, and social inappropriateness.
DLB is often misdiagnosed as Alzheimer’s or dementia of Parkinson’s disease (PDD) because of many overlapping symptomology. There are many things that separate DLB from PDD and Alzheimer’s. If the Parkinsonian symptoms are present for at least a year prior to the onset of dementia, then the diagnosis is PDD. Onset of dementia a year prior to or simultaneously with onset of Parkinsonian symptoms constitutes DLB. Patients with DLB are also less responsive to Levadopa. Memory deficits are also different in DLB versus AD. Patients with AD often have more difficulty acquiring and storing memories while those with DLB struggle with retrieving memories. They also show much more visuospatial and visuoperceptual dysfunction and attention deficits.
Examination & Assessment of DLB
The 3 main clinical domains of DLB are cognitive, psychiatric, and motor. Examination and assessment of motor features should include balance and fall risk. Tests that address visuospatial dysfunction should also be included. It is also important to note that one should avoid placing too much reliance on cognitive assessments due to the rapidly fluctuating nature of DLB.
Management of Dementia with Lewy Bodies
There is currently no cure for DLB. Treatments are focused on controlling cognitive and behavioral issues, Parkinsonian motor symptoms, and psychiatric symptoms.
Pharmacological Therapy
The standard pharmacological intervention for DLB is cholinesterase inhibitors to treat the cognitive symptoms. Levadopa is used to address the Parkinsonian motor symptoms. Levadopa is much more effective for Parkinson’s disease treatment, but patients with DLB also show improvements with use of Levadopa. Serotonin reuptake inhibitors are used to treat depression since DLB responds less favorably to tricyclic antidepressants. Clonazepam or melatonin is used to treat REM sleep issues if they are present. Extreme caution must be taken if neuroleptics are to be used to treat hallucinations. Neuroleptics can actually exacerbate DLB symptoms so they are typically avoided.
Nonpharmacological Management
As previously mentioned, individuals with DLB are at increased risk of falls. Therefore, they may benefit from prescription of assistive devices and mobility aids from occupational and physical therapy. Extensive training should be given with these aids and therapists should provide written instructions due to memory impairments. Education on fall prevention should also be given to the patient and caregivers. It may be necessary to make certain home modifications to improve safety of the environment such as removing rugs and clutter. Environmental modifications can also be made in order to help with the psychiatric issues that accompany DLB. For example, removing or covering mirrors may help prevent visual hallucinations or delusions. Also, when a patient is experiencing a hallucination, do not try to dispute or correct them but rather distract them or change locations.
Physical therapy programs can provide lots of additional benefits for patients with DLB. Exercise is a healthy and effective coping mechanism for stress and may help combat the depression that DLB patients often encounter. Physical therapists can also teach patients various relaxation techniques. Balance and fall prevention exercises should also be included.
Tips for Caregivers:
Resources
References